How to Set Up Chronic Care Management Programs

Key Steps to Set Up CCM:

• Understand CMS Requirements: Ensure patient eligibility, obtain consent, create digital care plans, and track time spent on care.

• Build a Skilled Team: Include care managers, clinical staff, practitioners, and administrative support.

• Use Technology: Adopt platforms like OnCare360 for time tracking, compliance monitoring, and billing.

• Establish Workflows: Standardize processes for patient enrollment, care plan creation, and care coordination.

• Ensure Accurate Billing: Follow CMS rules for documentation and use appropriate CPT codes (e.g., 99490, 99491).

Why CCM Matters:

• Better care for patients with chronic conditions.

• Reduced emergency visits and hospital readmissions.

• Increased revenue for practices through Medicare reimbursements.

Practice Hack: Chronic Care Management | Leveraging Care Management to Care for Patients at High Risk

Building Your CCM Team

Creating an effective Chronic Care Management (CCM) program starts with assembling the right team. The success of your program hinges on having skilled professionals who understand their responsibilities. A well-organized team ensures comprehensive care that complies with CMS guidelines, setting the stage for smooth operations and clear accountability.

Key Roles in a CCM Program

Each role in a CCM program plays a unique part in delivering high-quality care and ensuring compliance. Here's a closer look at the key players:

• Care Managers: These professionals, often registered nurses or licensed practical nurses, are the heart of your CCM program. They handle daily interactions with patients, monitor health conditions, and coordinate care. Their responsibilities include regular check-ins, medication reviews, and identifying potential health issues early.

• Clinical Staff: Nurses and medical assistants work closely with care managers, assisting with tasks like scheduling appointments, gathering initial health information, reconciling medications, and educating patients.

• Practitioners: Physicians, nurse practitioners, and physician assistants oversee the clinical aspects of the program. They review and approve care plans, make treatment decisions, and ensure that all clinical activities adhere to evidence-based practices, maintaining the program’s medical integrity.

• Practice Managers: These individuals manage the administrative side of CCM. They oversee billing, ensure CMS compliance, coordinate staff schedules, and act as a bridge between departments to support the program's financial health.

• Administrative Support Staff: This team handles documentation, data entry, and patient communication. Their work ensures accurate records for billing and compliance purposes.

Training and Skill Requirements

For a CCM program to run smoothly, the team must be well-trained in care coordination, documentation, technology, and communication. These skills are essential for maintaining compliance and delivering effective care.

• Documentation Skills: Detailed record-keeping is critical to meet CMS requirements. Team members must accurately log time spent on patient care, document communications, and maintain comprehensive care plan records to avoid billing errors and compliance issues.

• Technology Proficiency: With CCM programs relying heavily on electronic health records (EHR) and care management platforms, staff need to be comfortable navigating these systems. Proficiency ensures seamless tracking of patient progress and coordination of care activities.

• Communication Skills: Clear and empathetic communication is vital, as team members interact with patients regularly through phone calls, emails, or secure messaging. Explaining complex medical information in a way that builds trust is especially important for patients managing multiple chronic conditions.

The Importance of Collaboration

A successful CCM program thrives on teamwork. A well-coordinated team not only improves care delivery but also reduces unnecessary services, such as duplicate lab tests or imaging, which currently cost the healthcare system up to $20 billion annually.

To encourage collaboration, establish clear workflows that outline each team member’s responsibilities and communication protocols. Regular meetings and cross-training sessions can help solidify role understanding and improve coordination. For instance, cross-training allows care managers to learn about billing processes, while administrative staff gain insight into clinical priorities. This mutual understanding leads to a more flexible and efficient team.

Ongoing Education

As CMS requirements and best practices evolve, continuous education is essential. Regular training sessions keep staff informed about regulatory updates, new technologies, and improved care strategies. This ongoing learning not only enhances patient outcomes but also strengthens the program’s long-term sustainability. By focusing on clear roles, efficient workflows, and consistent training, your CCM program can achieve better care delivery and improved billing accuracy.

Using Technology for CCM

When you’ve got a solid CCM team and workflows in place, technology takes things to the next level. It simplifies care coordination and makes billing more efficient by smoothing out processes and reducing documentation hassles that often lead to claim denials. With a digital backbone in place, specialized tools can fine-tune care delivery even further.

Benefits of Care Management Platforms

Care management platforms can handle a lot of the heavy lifting when it comes to administrative tasks. By automating time tracking and centralizing patient data, these tools not only improve billing accuracy but also ensure compliance with CMS requirements. They embed key steps into daily clinical activities and enforce standardized documentation protocols, which helps avoid common errors like incomplete or unclear records. This structured approach doesn’t just save time - it ensures practices capture more billable hours and maintain audit-ready records, safeguarding their reimbursement streams.

EHR Integration and Data Security

For CCM programs to run smoothly, integration with Electronic Health Records (EHR) systems is a must. When patient data moves seamlessly between systems, care teams can access the most current information, leading to accurate and timely documentation. Strong data security measures, like encryption, audit trails, and role-based access, are equally important to protect patient data and meet HIPAA requirements.

With seamless EHR integration and strong security in place, practices can confidently adopt solutions like OnCare360.

OnCare360's CCM Features

OnCare360 is designed to reduce claim denials by providing clear workflows and ensuring audit-ready documentation. In October 2025, the platform demonstrated how it helps practices avoid common issues like missing consents, vague records, and overlapping billing. Its onboarding process includes consent collection and eligibility verification, minimizing billing risks from the start.

The platform’s certified care coordinators track their time directly within care management workflows, ensuring that documentation aligns with CMS billing and compliance requirements. OnCare360 also combines Chronic Care Management (CCM), Remote Patient Monitoring (RPM), and Transitional Care Management (TCM) into one streamlined solution. With built-in billing tools that flag potential issues before claims are submitted and monthly performance reviews that highlight areas for improvement, OnCare360 provides a comprehensive approach to optimizing care programs.

Setting Up CCM Workflows

Once your technology platform is ready, the next step is to establish workflows that guide patients through your Chronic Care Management (CCM) program. By combining your team's expertise with digital tools, you can design structured yet adaptable workflows to address each patient's specific needs.

Patient Enrollment and Consent

Start by identifying eligible patients within your practice. Review your electronic medical records to find Medicare beneficiaries who have at least two chronic conditions expected to last 12 months or longer - or until death - and that place them at significant risk of death, acute exacerbation, or functional decline. Additionally, confirm that these patients have had a qualifying visit with a provider in the last 12 months.

Educating patients about the benefits and services of CCM is an essential first step. Clear communication helps patients understand how the program can support them, which is key to obtaining their consent.

The consent process must be well-documented. Patients need to provide written consent that outlines the services offered, any associated costs, and their right to withdraw consent at any time. Make sure to maintain clear, easily accessible records of all consents.

Once consent is secured and eligibility confirmed, you can begin creating personalized care plans.

Creating Care Plans

After enrollment, the focus shifts to crafting care plans tailored to each patient. These plans serve as personalized roadmaps with specific, measurable goals and actionable steps. The aim is to address the patient as a whole person, not just their medical conditions.

Start with a thorough assessment of the patient’s medical history, functional abilities, social support systems, and any challenges with medication adherence. Actively involve the patient in setting goals - when patients help define their objectives, they’re more likely to stay committed to the plan.

Care plans should be treated as living documents. Regular reviews are essential to track progress, adjust goals, and modify strategies as a patient’s needs change. Medication management should also be a key part of the plan, as many patients take multiple medications, which can lead to potential interactions or adherence challenges.

Managing Care Coordination

Care coordination is critical to ensuring that all providers involved in a patient’s care are working toward the same health goals. This includes primary care physicians, specialists, and other healthcare professionals.

Schedule regular check-ins with patients, typically on a monthly basis, but adjust the frequency as needed depending on changes in their condition. These check-ins are opportunities to review medication adherence, address new or worsening symptoms, and prepare for upcoming appointments.

Establish clear communication protocols so care coordinators know when to escalate issues to a primary care physician and when they can handle concerns on their own. Well-defined escalation pathways are essential for responding promptly to urgent situations.

Tracking progress is equally important. Monitor key metrics such as medication adherence, emergency room visits, hospital readmissions, and quality-of-life scores. This data not only highlights the value of your CCM program but also helps refine and improve its services.

Finally, hold regular care team meetings to ensure all providers are aligned. Even short meetings can make a big difference. When appropriate, include the patient in these discussions to gain insights that might not be captured in clinical documentation.

Compliance and Billing for CCM

Adhering to CMS guidelines is critical for ensuring proper billing and compliance for Chronic Care Management (CCM). This section expands on earlier workflow discussions, focusing on key billing and compliance essentials.

CMS Billing Requirements for CCM

To bill for CCM services, CMS mandates at least 20 minutes of non-face-to-face care management each calendar month. These services must be provided by clinical staff under the supervision of a physician or qualified healthcare professional. Use CPT code 99490 to report the required non-face-to-face care management. If a physician personally contributes additional time, CPT code 99491 may apply.

Medicare beneficiaries should be informed that CCM services come with a 20% coinsurance for outpatient care, as part of the consent process.

The billing period runs from the 1st to the last day of the month. Even if services begin mid-month, the 20-minute minimum must still be met by month-end. For instance, if CCM services start on January 15th, the required time must be accumulated by January 31st to bill for that month. Activities eligible for billing include care plan creation, medication management, coordinating with other providers, and patient education.

Accurate documentation is the cornerstone of compliance. Since CMS routinely audits CCM claims, maintaining complete and defensible records is essential.

Documentation Best Practices

Training staff to document in real time can improve accuracy and completeness. Using standardized templates ensures key details are consistently captured, including:

• Date and time of service

• Duration of activity

• Staff member providing care

• Specific services performed

• Clinical outcomes or next steps

When recording patient phone calls, include information about medication adherence, symptom checks, care plan updates, and any follow-up actions or referrals. For care coordination efforts, make sure to document communications with specialists, pharmacists, or other providers, along with the purpose and outcomes of those interactions.

Detailed records of care plan development are equally important. This includes time spent reviewing medical records, analyzing patient data, consulting with physicians, and updating care plans. Each entry should clearly tie back to the patient’s chronic conditions and treatment goals.

To stay audit-ready, periodically review a sample of CCM documentation. This helps identify and address common issues like missing time stamps, vague service descriptions, or insufficient clinical rationale.

Finally, ensure all CCM-related records are stored in an accessible format. Whether using paper or electronic systems, auditors should be able to quickly locate and review documentation. Organizing files by patient and billing period can streamline this process.

Thorough documentation not only supports compliance but also ensures smoother billing - whether done manually or through automated systems.

Manual vs. Automated Billing

The choice between manual and automated billing can significantly influence your program's efficiency and accuracy. Here's a comparison:

Manual billing often consumes a significant amount of time, pulling care coordinators away from patient care to handle administrative tasks. Automated solutions, like OnCare360, simplify this process by automatically tracking billable minutes as staff document interactions. Built-in compliance checks further reduce the risk of errors that could lead to audits or claim denials.

Inaccurate tracking in manual systems can result in lost revenue, while automation ensures every billable minute is accounted for. As your CCM program expands, automated systems provide a more practical and efficient solution.

When deciding on a billing approach, consider your practice's size, technical resources, and future growth. While manual methods may seem cost-effective at first, the hidden costs of administrative work and billing errors often make automation the smarter investment in the long run.

Conclusion

Creating a successful Chronic Care Management (CCM) program involves four key steps: building a skilled team, implementing effective technology, designing efficient workflows, and ensuring precise billing practices.

Your team forms the backbone of the program. From care coordinators to administrative staff, every member plays a role in meeting CMS care standards. A well-trained and collaborative team not only ensures compliance but also delivers consistent, high-quality care. When combined with the right technology, their efforts can have an even greater impact.

Technology platforms like OnCare360 can transform how you manage CCM. By automating time tracking, monitoring compliance, and streamlining documentation, these tools eliminate much of the administrative burden associated with manual CCM processes. This not only reduces the risk of billing errors but also frees up your staff to focus on what really matters: patient care. The difference between manual and automated systems becomes even more pronounced as you scale your program to serve more patients.

Efficient workflows are equally critical. Clear processes for patient enrollment, care plan creation, and care coordination ensure your program remains compliant with CMS guidelines. Establishing protocols for obtaining patient consent, documenting interactions, and collaborating with other providers creates a solid foundation for operational success.

Accurate billing and compliance are essential to your program's financial health. Correct use of CPT codes 99490 and 99491, along with precise documentation and tracking of billable minutes, ensures you can confidently defend your claims during audits. Additionally, the 20% coinsurance requirement for Medicare beneficiaries should be clearly explained during the consent process to avoid confusion.

When set up properly, a CCM program can lead to better patient outcomes and sustainable revenue. Practices often report increased patient engagement, fewer emergency department visits, and improved coordination across specialties.

With its automation capabilities, OnCare360 ties all these components together into a seamless, audit-ready system. By addressing common challenges, the platform helps ensure your CCM program is built for long-term success and growth.

FAQs

1. What are the key CMS requirements for setting up a Chronic Care Management program?

1. To set up a Chronic Care Management (CCM) program, you’ll need to follow specific guidelines laid out by CMS. These ensure that patients with long-term health challenges receive the care they need while maintaining compliance with federal standards. Patients eligible for CCM must have at least two chronic conditions expected to persist for 12 months or more, or until the end of their life. These conditions should carry a heightened risk of serious outcomes, like death, sudden worsening, or loss of functionality.

   Here’s what’s required to get started:

   • Patient Consent: Patients must agree to participate, either verbally or in writing, before enrolling in the program.

   • Comprehensive Care Plan: You’ll need to create a tailored care plan for each patient. This plan must be electronic, kept up to date, and adjusted as necessary.

   • 24/7 Access: Patients must have access to CCM services at any time, day or night.

   • Detailed Medical Records: Proper documentation is key. This includes recording patient eligibility, consent, care plans, and the time spent on CCM-related activities.

   Following these steps not only ensures compliance with CMS rules but also supports better care coordination for individuals managing chronic conditions.
   
   

2. How can care management technology improve the effectiveness and compliance of a Chronic Care Management (CCM) program?

1. Care management technology, such as electronic health records (EHRs) and other tailored platforms, plays a key role in boosting the efficiency and compliance of a Chronic Care Management (CCM) program. These tools bring all patient information into one place, making it simpler to review medical histories, spot trends, and coordinate care seamlessly. When integrated with your EHR system, they help minimize errors, break down information silos, and ensure that detailed patient records are readily available when needed.

   On top of that, features like telephonic communication tools and secure messaging are game-changers for patient engagement. These are especially valuable for individuals in rural areas or older adults who might struggle with in-person visits. By making communication easier and more accessible, these technologies not only enhance service delivery but also help meet CMS requirements. The result? Better patient outcomes, smoother billing processes, and a more connected approach to care.
   
   

3. What are the key roles in a care team, and why are they important for a successful Chronic Care Management (CCM) program?

1. A well-structured care team is essential for the success of any Chronic Care Management (CCM) program. It ensures smooth coordination and helps improve patient outcomes. Here’s a breakdown of the key roles involved:

   • Qualified Healthcare Professionals (QHPs): These are licensed providers like physicians, nurse practitioners, and physician assistants. They oversee care delivery and are responsible for billing CCM services.

   • Clinical Staff: This group includes nurses, pharmacists, and other licensed professionals who provide hands-on patient care under the supervision of QHPs.

   • Non-Clinical Staff: Office managers and administrative staff handle tasks like scheduling and communication, keeping operations running efficiently.

   • Care Managers: These team members focus on maintaining consistent care by engaging with patients and coordinating services.

   Together, these roles create a patient-focused system that not only enhances care but also ensures compliance with CMS guidelines and optimizes billing processes.